From the Guidelines
For a patient with a CIWA score of 12 who is not responding well to Ativan and has pulled out their IV, I recommend switching to oral benzodiazepines such as diazepam (Valium) 10-20 mg or chlordiazepoxide (Librium) 50-100 mg orally every 4-6 hours as needed, as they are considered the 'gold standard' treatment for AWS 1. The patient's CIWA score of 12 indicates a moderate to severe alcohol withdrawal syndrome, and the fact that they are not responding well to Ativan suggests that a different benzodiazepine may be necessary.
- The use of oral benzodiazepines such as diazepam or chlordiazepoxide is recommended because they have longer half-lives than Ativan, providing more stable coverage for alcohol withdrawal symptoms 1.
- Additionally, adjunctive medications like gabapentin 300-600 mg three times daily or carbamazepine 200 mg three times daily can help manage withdrawal symptoms.
- It is also essential to ensure the patient is receiving adequate hydration, thiamine supplementation (100 mg daily), and electrolyte replacement, particularly magnesium and potassium.
- Close monitoring of vital signs and CIWA scores should continue, with reassessment every 1-2 hours, to prevent progression to severe withdrawal complications like seizures or delirium tremens 1.
- If symptoms worsen despite these interventions, consider transferring the patient to a higher level of care for more intensive monitoring and possibly continuous benzodiazepine infusion.
From the FDA Drug Label
Acute Alcohol Withdrawal: As an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. 10 mg, intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary. The patient's CIWA score is 12, indicating moderate to severe alcohol withdrawal symptoms. Since the patient is not responding well to Ativan, diazepam (IV) can be considered as an alternative treatment. The recommended initial dose for acute alcohol withdrawal is 10 mg, intramuscular or intravenous. However, given the patient's condition and the fact that they pulled out their IV, caution should be exercised when administering the medication, and alternative routes of administration should be considered.
- Key considerations:
- The patient's vital signs and respiratory status should be closely monitored.
- The dose may need to be adjusted based on the patient's response to treatment.
- Respiratory assistance should be readily available. 2
From the Research
Patient Not Responding to Ativan
- The patient's CIWA score is 12, indicating moderate to severe alcohol withdrawal symptoms 3.
- The patient is not responding well to Ativan (lorazepam), which is a commonly used medication for alcohol withdrawal 4, 5, 6.
- The patient has also pulled out their IV, which may indicate agitation or discomfort.
Alternative Treatment Options
- Phenobarbital has been shown to be an effective adjunctive therapy for severe alcohol withdrawal, reducing benzodiazepine use and improving outcomes 4, 5, 6.
- A study found that patients who received phenobarbital had a statistically significant shorter hospital length of stay and lower rates of all-cause 30-day readmission and 30-day ED visits after discharge 4.
- Another study found that phenobarbital was an effective adjunct to symptom-triggered lorazepam in severe alcohol withdrawal in the ICU, with no significant difference in adverse events 5.
Considerations for Treatment
- The use of benzodiazepine-sparing treatments, such as gabapentin, valproic acid, clonidine, and dexmedetomidine, may be considered as an alternative to traditional benzodiazepine-based therapy 7.
- A study found that implementation of a benzodiazepine-sparing alcohol withdrawal order set was associated with decreased use of benzodiazepines and favorable trends in outcomes 7.
- Symptom-triggered dosing of lorazepam may be effective for patients with medical comorbidity, but may result in a higher proportion of protocol errors 3.